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F0610
D

Failure to Investigate and Report Alleged Abuse by Family Member

Madison, Wisconsin Survey Completed on 12-05-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported and thoroughly investigated according to state law and facility policy. On 10/22/25, an allegation of verbal abuse by a family member toward a resident was reported to the facility. Witnesses, including another resident and a visitor, described hearing and seeing the family member yelling, using profanity, and throwing a hanger in the resident's room. Both witnesses reported the incident to Social Services, who in turn reported it to the previous Nursing Home Administrator. Despite these reports, the facility did not conduct a thorough investigation, did not interview the resident involved, and did not obtain written witness statements as required by policy. The resident involved was cognitively intact, as indicated by a recent BIMS score of 13. Staff cited the family member's status as activated power of attorney as a reason for not interviewing the resident, stating that the family member required to be present for any staff interaction with the resident. No interventions or plans were implemented to ensure the resident's safety or to prevent further abuse, and the incident was not reported to the appropriate authorities as required by federal and state regulations. The facility's inaction was confirmed by both Social Services and the current Nursing Home Administrator during interviews.

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